Step 1 of 5 20% Part 1: Client RegistrationCLIENT LAST NAME* FIRST* MIDDLE INITAL* HOME PHONE*CELL PHONE*ADDRESS* CITY* STATE* ZIP* COUNTY* GENDER* AGE*DATE OF BIRTH* MM slash DD slash YYYY SOCIAL SECURITY NUMBER For your security, your social security number will not be collected online. We will request your SSN via the telephone.EMAIL ADDRESS* EMPLOYER* CITY* STATE* ZIP* MAY WE CALL AND/OR LEAVE A MESSAGE FOR YOU AT* HOME WORK CELL ALL EMAIL NONE SHIFT* AM PM NIGHT WEEKEND N/A SPOUSE/PARTNER LAST NAME FIRST MIDDLE INITIAL DATE OF BIRTH MM slash DD slash YYYY ADDRESS (IF DIFFERENT) HOME PHONECELL PHONEPARENT/LEGAL GUARDIAN (IF CLIENT IS MINOR) ADDRESS (IF DIFFERENT) HOME PHONEDATE OF BIRTH MM slash DD slash YYYY SOCIAL SECURITY NUMBER For your security, your social security number will not be collected online. We will request your SSN via the telephone.EMPLOYER EMERGENCY CONTACT* RELATIONSHIP* PHONE NUMBER* Part 2: ConcernsWHY ARE YOU SEEKING COUNSELING AT THIS TIME?* ADOPTION ISSUES ANGER MANAGEMENT ANXIETY/STRESS BEHAVIORAL PROBLEMS DEPRESSION GRIEF/LOSS HYPERACTIVITY/IMPULSIVITY RELATIONSHIP ISSUES SELF-ESTEEM WORK-RELATED ISSUES OTHER OTHER (PLEASE EXPLAIN)IF SOMEONE REFERRED YOU TO CORNERSTONE, PLEASE TELL US WHO? Part 3: Service Fee Agreement Payment is due at the time services are rendered unless other arrangements have been made. Cornerstone makes every reasonable effort to obtain benefit information from insurance companies. However, information quoted by insurance companies is no guarantee of payment. Therefore, you must understand that it is sole responsibility of the client or parent/guardian, not the insurance company, to pay for any and all services provided by Cornerstone. Cornerstone files insurance claims as a courtesy. Co-payments are due at the time services are rendered. Your appointment times are reserved for you. If you are unable to keep your appointment, please notify our office 24 hours in advance. You may be charged for missed appointments at the discretion of your care provider. Insurance companies will not pay for missed appointments. We reserve the right not to reschedule clients who repeatedly fail to keep appointments. I affirm that I have read, understood and agree to abide by this fee policy. By my signature below, I acknowledge that I am the party responsible for payment and accept the agreement above. I also understand and acknowledge that I am personally responsible to pay Cornerstone in full for services that my health insurer will not cover due to non-payment of my health insurance premiums.”SIGNATURE OF CLIENT/PARENT/GUARDIAN* Reset signature Signature locked. Reset to sign again CLIENT NAME* Reset signature Signature locked. Reset to sign again DATE Part 4: Client RightsYOUR RIGHTS AS A CLIENT OF CORNERSTONECLIENT Please review the information below and let your service provider know if you have any questions. We are committed to working with you to achieve your goals. To make the most progress as quickly as possible, we invite you to: Identify the main concerns you want to work on. Monitor your progress toward goals. Keep us informed of whether our partnership is on track. Our relationship with you and your family is confidential. The only times we can disclose information are under the following circumstances: In situations where we are court ordered to do so. In situations where someone is in danger and appropriate safety action must be taken. In situations where child or elder abuse or neglect is suspected. The records we keep are available for you to see. Please talk with your therapist or case manager if you would like to review your records. We believe that working together produces the best results for you. You will not be discriminated against with regard to your age, sex, race, religion, marital status, national origin, or disability. You can refuse or terminate services at any time, and we will do our best to explain any consequences which could result from a refusal of services. If at any time you are not happy with the services you are receiving, please talk it over with your therapist, case manager, or the Clinical Supervisor. We will not deny, suspend, or terminate services due to exercising any of these rights. CONSENT TO SERVICES AND ACKNOWLEDGMENT OF RIGHTS I hereby consent to receive counseling, rehabilitative mental health, or psychiatric services at Cornerstone. I have reviewed a copy of this notice of my rights. I have had a chance to have my questions answered about my rights. I further acknowledge receipt of Cornerstone's Notice of Privacy Practices on the date below.Signing Applicant is 12 years or over CLIENT* Reset signature Signature locked. Reset to sign again PARENT/LEGAL GUARDIAN* Reset signature Signature locked. Reset to sign again DATE* MM slash DD slash YYYY Part 5: Insurance InformationPRIMARY INSURANCE (PLEASE ALLOW RECEPTIONIST TO PHOTOCOPY YOUR INSURANCE ID CARD)PLAN NAME INSURED’S NAME (IF OTHER THAN CLIENT) INSURED SOCIAL SECURITY NUMBER For your security, your social security number will not be collected online. We will request your SSN via the telephone.INSURED’S DATE OF BIRTH MM slash DD slash YYYY POLICY/ID NUMBER GROUP NUMBER EFFECTIVE DATE MM slash DD slash YYYY CLAIMS ADDRESS CLAIMS PHONEDEDUCTIBLE CO-PAY VERIFIED INITIAL & DATE Reset signature Signature locked. Reset to sign again SECONDARY INSURANCE (PLEASE ALLOW RECEPTIONIST TO PHOTOCOPY YOUR INSURANCE ID CARD)PLAN NAME INSURED’S NAME (IF OTHER THAN CLIENT) INSURED SOCIAL SECURITY NUMBER For your security, your social security number will not be collected online. We will request your SSN via the telephone.INSURED’S DATE OF BIRTH MM slash DD slash YYYY POLICY/ID NUMBER POLICY/ID NUMBER GROUP NUMBER EFFECTIVE DATE MM slash DD slash YYYY CLAIMS ADDRESS CLAIMS PHONE Cornerstone receives funding from a variety of sources. Some funding sources, including the United Way of Adams County, ask us for demographic information related to the people we serve. No personally identifiable information is ever shared with any funding source except your insurance company if applicable or as described in our Notice of Privacy Practices. Completion of this form is voluntary. Your decision to provide the information will not affect your treatment. If you are participating in a United Way funded program, your responses are required. TOTAL NUMBER OF PEOPLE IN YOUR HOUSEHOLD*(PLEASE LIST BELOW OTHERS NOT LISTED ON PAGE 1)HOUSEHOLD MEMBERSWILL ANY OF THESE HOUSEHOLD MEMBERS BE INVOLVED WITH TREATMENT* YES NO UNCERTAIN PLEASE RESPOND TO THE FOLLOWING FOR THE PERSON LISTED AS CLIENT ON PAGE 1MARITAL STATUS* SINGLE MARRIED SEPARATED DIVORCED WIDOWED EDUCATION* K THRU 8TH SOME HIGH SCHOOL HIGH SCHOOL GRAD VOCATIONAL SCHOOL SOME COLLEGE 2 YR COLLEGE DEGREE 4 YR COLLEGE DEGREE GRAD DEGREE DOCTORATE EMPLOYMENT* FULL-TIME PART-TIME RETIRED HOMEMAKER UNEMPLOYED-LONG TERM UNEMPLOYED-SEASONAL STUDENT HOUSING* OWN/FAMILY HOME RENT/LEASE GROUP QUARTERS SHELTER HOMELESS OTHER IF THE PERSON LISTED AS THE CLIENT ON PAGE 1 IS A CHILD, PLEASE RESPOND TO THE FOLLOWING FOR THE HOUSEHOLD IN WHICH THE CHILD LIVESHEALTH INSURANCE* PRIVATE PUBLIC (MEDICAID) NONE INCOME (SEE TABLE)* ABOVE POVERTY LEVEL BELOW POVERTY LEVEL FEDERAL POVERTY GUIDELINES FAMILY SIZE 1 2 3 4 5 6 7 8 ANNUAL INCOME $11,770 $15,930 $20,090 $24,250 $28,410 $32,570 $36,730 $40,890 THANK YOU FOR YOUR COOPERATION IN COMPLETING THIS FORM! FOR USE BY CORNERSTONE STAFFPROGRAM ID NUMBER STAFF MEMBER
